Advanced kidney disease: end of life care

Encompass the person’s supportive and palliative care needs over a time period which may vary in lasting for weeks, months or years for those people with advanced kidney disease irrespective of treatment modality.

Diagnosis
The Gold Standards Framework (GSF) prognostic indicator guidance describes general triggers. These include:
- significant weight loss (> 10% over 6 months)
- severe hypoalbuminaemia (serum albumin < 25 g/l).
- patients with stage 4 or 5 CKD whose condition is deteriorating with at least 2 of the indicators below:
• Patients for whom the "surprise question" is applicable i.e. “would you be surprised if this patient were to die in the next 6 to 12 months?”
• Patients choosing the no dialysis option, discontinuing dialysis or opting not to start dialysis if their transplant is failing
• Patients with difficult physical symptoms or psychological symptoms despite optimal tolerated renal replacement therapy.

Clinical
- Debility / unintentional weight loss / decline in performance status / spending most of time in bed / decubitus ulcers / dysphagia resulting in poor nutrition.
- Dialysis related: persistent and problematic hypotension on haemodialysis and peritoneal dialysis not feasible.
- Cardiovascular: recurrent chest pain at rest or on dialysis with no options of cardiac intervention and not responding to medical therapy / unable to carry out any physical activity without chest pain or shortness of breath.

Management
The plan should:
- Record the person’s preferences and the choices they wish to make including, when appropriate, their views on resuscitation.
- Provide effective symptom control. Pain, agitation, myoclonus, dyspnoea, nausea and respiratory tract secretions, are major symptoms in patients with advanced kidney failure in the last days. It is good practice to prescribe in anticipation of common symptoms deploying the easiest and least invasive route of administration.

Related terms

Initial development of Pallipedia was funded by a grant from the US Cancer Pain Relief Committee.​ Ongoing development and maintenance is funded by Fundación FEMEBA, Argentina.
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